Background/Rationale The VA has been a national leader in electronic health record (EHR) implementation including the availability of Computerized Patient Record System (CPRS) enabled workstations in ambulatory exam rooms. Despite this fact, there is evidence of wide variability in CPRS use by individual providers and across VA facilities during ambulatory encounters. This variation in computer use before, during, and after the patient encounters leads to questions of how best to integrate CPRS into clinical workflow and how this variation in computer use impacts patient- centered care. Veterans' health outcomes may ultimately be compromised by variations in the implementation of this technology. For example, where CPRS use in encounters is low, physicians may not consistently receive all clinical reminders and patients may not receive all interventions that might improve their outcomes. Objectives The objective of this proposal is to understand variations in the use of CPRS- enabled exam room computers and how use or non-use affects patient-centered communication and clinical workflow during outpatient primary care visits. We have two specific aims: Specific Aim 1. Describe variations in how providers employ CPRS during ambulatory care encounters at 3 VA facilities. Specific Aim 2. Identify barriers and facilitators to the integration of CPRS into routine ambulatory care workflow. Methods We propose a multi-site, multi-method study with two main components: 1) ethnographic observations of CPRS use throughout the entire ambulatory care process including pre-visit preparation, the face-to-face encounter between provider and patient, and post-visit documentation (Aim 1); and 2) in-depth interviews and surveys to ascertain individual and facility-level perceptions of barriers and facilitators associated with CPRS usage (Aim 2). As part of the ethnographic observations, we will videotape the provider-patient encounters, which will enable us to describe the impact of exam room computers on patient centeredness and workflow. Impact on Veterans' Healthcare Results from this study will help us design strategies to reduce barriers to CPRS use and better integrate CPRS into clinical workflow in order to enhance patient care. The results will help us work with VA providers to optimize patient-centeredness during patient encounters and improve CPRS effectiveness. The inextricable link between provider-patient communication and patient outcomes, coupled with the widespread use of CPRS in the VA, clearly illustrates that this research is essential to improve veteran care.